What i s . ..? For further titles in the series, visit: www.whatisseries.co.uk What is commissioning?

Michael Sobanja Dip HSM Dip IoD Cert HE FRSM Director of Policy, NHS Alliance

G The origin of commissioning rests in a 1989 political G NHS finances are under immense pressure. A provider attempt to revive an ailing NHS. overspend of £2.45 billion in 2015/16 was offset by a national underspend by NHS England and specialised G The purchaser–provider split aimed to separate bodies commissioning. concerned with the ’what‘ from those concerned with the ’how’. G In 2015/16, 62 CCGs reported underspends totalling £122 million against their annual plan, while 39 CCGs G Commissioning responsibilities are now divided across reported overspends totalling £151 million. NHS England, clinical commissioning groups (CCGs) and local authorities. G The Cancer Drugs Fund overspent by £126 million (37%) despite reprioritisations undertaken during G Co-commissioning is a term that may apply to the year. both specialised commissioning and primary care commissioning. It seeks to involve CCGs in G From 1 st April 2016, the Greater Manchester Combined commissioning services for which NHS England is Authority took control of a £6 billion health and social legally accountable. care budget.

G Specialised commissioning is concerned with services G Further devolution arrangements, varying in their provided in relatively few hospitals but these usually type, have been announced. These involve Cornwall, have catchment populations of more than one million Liverpool and London. people. The budget is £15.6 billion. G The Five Year Forward View sets the scene for the G More than half of all CCGs have taken devolved period up to 2020. responsibility for commissioning general practice services from 1 st April 2016. G From 2016, every health and care system in England (44 in total) will produce a multi-year Sustainability G Commissioning support units (CSUs) provide and Transformation Plan (STP), showing how local business services to commissioners. There are services will evolve and become sustainable over the currently six NHS CSUs. next five years.

EVIDENCE-BASED HEALTHCARE theory • knowledge • practice What is .. .? What is commissioning?

Historical context ’how care should be provided’. & brief history Of course, politicians tinker and the NHS as After the general election in 1987, the then a federated model fails to deliver consistently. prime minister, Margaret Thatcher, was faced Over twenty years on, commissioners still vary with the need to take action about an NHS in their approach, those at the centre of the challenged by inadequate funding, long NHS (perhaps mistakenly) maintain an waiting lists for elective surgery and a wide essentially heavy-handed performance variation in care and outcomes, most of management and controlling regime, and which persist to this day. The election had commissioning has arguably failed to deliver; crystallised public concern and turned NHS it certainly has not fixed the NHS. Some reform into a political imperative. suggest commissioning is coming to the end Commissioning was the ’fix’. of its life and is simply part of a never-ending An internal confidential inquiry followed, cycle of ‘reform by experiment’ in the discarded the option to increase the role of healthcare system in England. private insurance and created an internal There will always have to be a mechanism market – the so-called purchaser–provider split for dividing up the national budget, deciding in healthcare. Commissioning, an ill-defined how and on what it is spent, and holding those term for decades, was born. Health authorities who provide clinical care to account. The were given allocations to ’purchase‘ care from current mechanism is commissioning – but the ’provider organisations‘ and NHS trusts came activities involved take place in Scotland, Wales into being. Over time, commissioning and Northern Ireland using a different arrangements have evolved, with primary care vocabulary. Although the players and lexicon trusts, local commissioning groups, GP may differ, the principles remain the same. fundholders and others all having a role. A key change brought about by the The thinking behind the term Health and Social Care Act 2012 was that of ‘commissioning’ – and its associated processes the commissioning structure in England. This – was summed up by the Health Committee change saw the further fragmentation of of the House of Commons in 2009: commissioning across the system. The act led G ‘It was thought that, whereas in the past, to the creation of: NHS England, which took providers, usually hospital doctors, had largely responsibility for the commissioning of determined what services would be provided, specialised services and primary care services; now commissioning bodies would act on clinical commissioning groups (CCGs) , which behalf of patients to purchase the services that secure general health services (mostly were really needed. “Purchasers” (health hospital services) for local communities; and authorities and some family doctors) were local authorities, which take responsibility for given budgets to buy healthcare from commissioning prevention and some “providers” (acute hospitals, organisations treatment services. This is shown providing care for people with mental health diagrammatically in Figure 1. problems, people with learning difficulties, older people and the ambulance service). To Specialised commissioning become a “provider” in the internal market, Specialised services are those provided in health organisations became NHS “trusts”, relatively few hospitals that are accessed separate organisations with their own by comparatively small numbers of patients management, and the stated aim was a more but usually have catchment populations of efficient health service and one run more in the more than one million. These services tend to interests of patients than hospital doctors.’ 1 be located in specialised hospital trusts that Perhaps the most important issue to grasp can recruit a team of staff with the when discussing commissioning, is that it was appropriate expertise and enable them to a political response to a troubled NHS, and develop their skills. rested upon an ideology that saw a separation NHS England is responsible for of commissioners, whose principal task was to commissioning £15.6 billion 2 worth of focus on the ’what and how much‘, from specialised services to meet a wide range of providers, who were to take responsibility for health and care needs. The range of services

2 www.whatisseries.co.uk What is .. .? What is commissioning? it commissions includes, for example, renal NHS England CCGs Local authorities dialysis, secure inpatient mental health services, and treatments for rare cancers and • Specialised services • Planned hospital • Smoking cessation life-threatening genetic disorders. The • Four primary care services • Urgent emergency care • Alcohol and drug misuse commissioning of specialised services is a – Community pharmacy • Rehabilitation care • Public health servcies for prescribed direct commissioning – General medical • Community health children responsibility of NHS England. services (GPs) services • Sexual health servcies Four factors determine whether NHS – Optometrists • Mental health and • Obesity – Dentistry learning disability services • Other public health England commissions a service as a improvement services prescribed specialised service. These are: G the number of individuals who require the service Co-commissioning G the cost of providing the service or facility G the number of people able to provide the service or facility Figure 1. Who commissions what? G the financial implications for CCGs if they were required to arrange for provision of place for the procurement, selection and use the service or facility themselves. of medicines in secondary care are as effective Specialised commissioning is to be as possible in supporting patients to take their achieved through the development of clinical medicines and in reducing harm from strategies set out within six national medicines, while ensuring best value. programmes of care (PoCs), which group The ambition of NHS England is to together a nationally agreed range of bring equity and excellence to the specialised services. This strategy enables the provision of specialised care and treatment. commissioning of services to be based on This is achieved through a commissioning clear evidence and ensure that they are cost- process that: effective and patient-focused. The six national G is patient-centred and outcome-based – PoCs are: the patient must be placed at the centre of G Internal medicine – digestion, renal, planning and delivery, and commissioners, hepatobiliary and circulatory system working with providers, must deliver G Cancer improved outcomes for them across each G Mental health of the five domains of the 2013/14 NHS G Trauma – traumatic injury, orthopaedics, Outcomes Framework head and neck, and rehabilitation G is fair and consistent throughout the G Women and children – women and country, ensuring that patients have children, congenital and inherited diseases equal access to services, regardless of G Blood and infection – infection, immunity their location and haematology. 3 G improves productivity and efficiency. 2 The direct specialised commissioning function of NHS England is supported by a Co-commissioning of devolved clinical leadership model. Clinical specialised services reference groups (CRGs) covering all In April 2014, NHS England established a task prescribed specialised services draw force for specialised commissioning to analyse membership from geographical areas . They the current commissioning arrangements and are responsible for preparing a national, identify options for new approaches with the specialised service-level strategy and potential to improve the services developing specialised service contract commissioned on behalf of patients and products such as specifications and policies. taxpayers within the resources allocated by the The Specialised Commissioning Medicines board for this purpose. The work of the task Optimisation CRG works across all 75 service- force – drawing on input from a wide range of specific CRGs. One of its key roles, working stakeholders – identified that some services with experts from around the country, is to would be better commissioned in partnership ensure that the systems and levers currently in with CCGs rather than in isolation of the local

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services with which they are inextricably G improved access to primary care and wider linked. NHS England said it wanted to build on out-of-hospital services with more services the success of CCGs to date by giving them the available closer to home opportunity to play a greater role in the G high-quality out-of-hospital care commissioning of all health services for the G improved health outcomes, better access populations they serve. 4 This approach was to services and reduced health inequalities signalled in its Five Year Forward View .5 G a better patient experience through more This means that although NHS England joined-up services. 7 will continue to retain accountability for NHS England has invited CCGs to take on specialised services, CCGs will be formally an increased role in the commissioning of GP invited to collaborate in determining what services through three co-commissioning services are purchased. models: G greater involvement – an invitation for Primary care commissioning CCGs to collaborate more closely with their The commissioning of the four primary care local NHS England teams in decisions services – general practice, dentistry, about primary care services to ensure that community pharmacy and optometry – now healthcare services are strategically aligned rests with NHS England. It was initially across the local area undertaken by the 27 local area teams, which G joint commissioning – enables one or more were subsequently abolished and replaced by CCGs to jointly commission GP services with four regional offices. Primary care services were NHS England through a joint committee previously commissioned by primary care G delegated commissioning – offers an trusts, which were abolished on 31 st March opportunity for CCGs to assume full 2013. As a result, GP practices are in contract to responsibility for the commissioning of GP NHS England for nearly all of their provisions, services. 7 including the core contract and enhanced The introduction of co-commissioning services (formerly, directed enhanced services). has elicited a strong response and by 1 st April National directions currently cover the 2016, a vast number of CCGs have taken on following enhanced services : an increased role in the commissioning of GP G Childhood Immunisation Scheme services, with 115 CCGs taking on full G Influenza and Pneumococcal Immunisation delegated responsibility. This means that Scheme over half the CCGs have delegated G Violent Patients Scheme responsibility in 2016/17 and a third of CCGs G Minor Surgery Scheme are operating under joint arrangements. 7 G Extended Hours Access Scheme The NHS Five Year Forward View signals a G Learning Disabilities Health Check Scheme clear and continued shift towards G Avoiding Unplanned Admissions and commissioning based on the specific needs of Proactive Case Management Scheme. 6 a local area and its patients. In 2016/17, NHS Some locally enhanced services may be England is exploring options for the possible commissioned by local authorities or CCGs. expansion of co-commissioning into wider primary care areas, with full and proper Co-commissioning of engagement of CCGs, NHS clinical primary care services commissioners and the relevant professional Primary care co-commissioning is one of a groups. This includes community pharmacy, series of changes set out in the Five Year where scoping work will focus on how Forward View . partnership working between NHS England Co-commissioning in this area aims to and CCG commissioners can be strengthened. support the development of integrated out- of-hospital services based around the needs Local authority of local people. It is part of a wider strategy to commissioning join up care in and out of hospital and could The new public health system, implemented lead to a number of benefits for patients and from April 2013, saw local authorities take the the public, including: lead for improving health, co-coordinating

4 www.whatisseries.co.uk What is .. .? What is commissioning? local efforts to protect the public’s health and ensuring that health services promote Box 1. Local authority commissioning population health. responsibilities At the same time, Public Health England • Tobacco control and smoking cessation services was created to deliver a range of services – • Alcohol and drug misuse services including health protection, providing • Public health services for children and young people information and intelligence, and supporting aged 5–19 years (including the 5–19 Healthy Child Programme the development of the public health and, in the longer term, all public health workforce. services for children and young people) • The National Child Measurement Programme Services that local authorities are • Interventions to tackle obesity, such as community responsible for commissioning include: lifestyle and weight management services G smoking cessation • Locally led nutrition initiatives G alcohol and drug misuse • Increasing levels of physical activity in the local population G public health for children • NHS Health Check assessments G sexual health • Public mental health services • Dental public health services G obesity • Accidental injury prevention G 8 other public health improvements . • Population-level interventions to reduce and prevent Box 1 provides a complete list of services. birth defects • Behavioural and lifestyle campaigns to prevent cancer and long-term conditions Fragmentation? One of the problems presented by the • Local initiatives on workplace health current arrangements is a fragmentation of • Supporting, reviewing and challenging the delivery of key public health-funded and NHS-delivered services, such as commissioning across the three immunisation and screening programmes arrangements – local, national and public • Comprehensive sexual health services (including testing and health. This can be problematic for both treatment for sexually transmitted infections, contraception patients and organisations. The level of outside of the GP contract, and sexual health promotion and fragmentation is illustrated in Figure 2 , which disease prevention) • Local initiatives to reduce excess deaths as a result of shows the commissioning responsibilities in seasonal mortality 9 a generic cancer pathway. • The local authority role in dealing with health protection Perhaps of greater concern is the failure of incidents, outbreaks and emergencies the new system to integrate commissioning • Public health aspects of promotion of community safety, across primary care, specialised care and violence prevention and response general care or, put another way, joined-up • Public health aspects of local initiatives to tackle social exclusion working between NHS England’s specialised • Local initiatives that reduce the public health impacts of commissioning functions, the regional teams environmental risks and CCG activities. The outgoing Chief Executive of NHS England, Sir David Nicholson, rated the organisation’s own spent on non-clinical services and although direct commissioning functions as ‘five out of CSUs do not provide direct patient care or ten’ at a speech at the Commissioning LIVE treatment, they play an essential role across conference in March 2014, 10 whereas his England in helping commissioners to successor, Simon Stevens, has broadly improve patient care and achieve substantial accepted that too many services are now savings, freeing up more money for being commissioned by his organisation reinvestment in frontline clinical services. 12 under the banner of specialist services. 11 The units are designed to provide excellent, affordable, commissioning support Commissioning services that enable clinical commissioners support units to maximise resources and focus their clinical Commissioning support units (CSUs) provide expertise and leadership on securing the commissioning support services to NHS best outcomes for patients and driving up the commissioners, including local CCGs, NHS quality of NHS patient services. 12 England, acute trusts and local government. 12 The competitive advantage of CSUs lies in Commissioning support is NHS money their breadth of skills, experience, expertise

www.whatisseries.co.uk 5 What is .. .? What is commissioning? and affordability. They can offer customers a GP wide range of professional services at scale, referral Radiotherapy which are critical to successful clinical commissioning. CSU specialist support services include: A&E Diagnostics Chemotherapy Follow-up surveillance G contract management G business intelligence G information governance Specialist Rehabilitation Screening surgery and G financial management survivorship G human resources, estates and information technology support ■ CCG Non-specialist Pallaitive care/ G clinical procurement ■ NHS England – specialist commissioning surgery end-of-life care ■ NHS England – public health G non-clinical purchasing G communications and patient engagement G bespoke services such as individual Figure 2. Generic cancer pathway – commissioning funding request management, infection responsibilities 9 prevention, governance and quality. 12

CSUs are not geographically defined. This 15 Table 1. NHS budget summary 2015/16 means that, in some cases, customers are Net expenditure local or regional clinical commissioners, whereas in other cases, they include CCGs in Plan Outturn Under/(over)spend other parts of England. Some CSUs also £ million £ million £ million % provide services to NHS England, local government and acute trusts. 12 Clinical commissioning groups 72,548.0 72,564.0 (16.0) (0.0%) Originally, 23 CSUs were formed, which Direct commissioning 26,806.2 26,723.8 82.4 0.3% were reduced relatively quickly to 18. More Running, programme costs and other 1,766.4 1,310.1 456.3 25.8% recently, the overall number of NHS CSUs has reduced to six, as listed below: Total before technical adjustments 101,12-.6 100,597.9 522.7 0.5% G NHS South, Central and West CSU Technical and ring-fenced adjustments (238.2) (314.9) 76.7 G NHS Midlands and Lancashire CSU G NHS North and East London CSU Total non-ring-fenced RDEL 100,882. 100,283.0 599.4 0.6% G NHS North of England CSU under/(over)spend 4 G NHS South East CSU RDEL = Revenue Departmental Expenditure Limit G NHS Arden and Greater East Midlands CSU. Other areas of the UK are now covered by concluded the following: private providers offering the same services, G ’At the year-end, 62 CCGs reported such as Capita, Optum and the eMBED Health underspends totalling £122m against their Consortium, which consists of the health annual plan and 39 CCGs reported overspends information business Dr Foster, advisory firm totalling £151m. The overall CCG position Mouchel Consulting, accountancy firm BDO benefitted from a £13m underspend on and consultancy Engine. 13,14 Quality Premium. 31 CCGs finished the year Currently governed by NHS England, with cumulative deficits, 10 of which were CSUs are intended to become autonomous unplanned. The measures to improve CCG organisations in 2016 and be fully resilience, which we have taken in 2015/16, established, self-sustaining entities in a have resulted in fewer overspends and a competitive market. 12 reduction in the scale of individual financial deficits (in 2015/16 the largest CCG overspend 15 Financial stringency was 5% compared to 10% in 2014/15).’ The NHS has a legal duty to operate within its G ‘For the first time in recent history, specialised statutory budget. The overall financial commissioning achieved a small underspend position for 2015/16, as reported by NHS (£14m) on its operational performance, England, is shown in Table 1 .15 reflecting the significant programme of In the same report, NHS England measures undertaken over the last two years

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to improve management processes and Table 2. STP footprints by NHS region 21 15 controls.’ NHS region Total number of STP Average number of CCGs Average footprint G ‘The Cancer Drugs Fund (CDF) overspent by footprints per footprint a populationb (million) £126m (37%), despite reprioritisations undertaken during the year. A new approach England 44 4.8 1.2 to prioritisation and management of drugs North 9 7.4 1.7 within the fund will be introduced in July Middle and East 17 3.6 1.0 2016 following the recent consultation process in partnership with NICE to seek to London 5 6.4 1.7 ensure that the fund remains within the South 13 3.8 1.1 agreed envelope of £340m’. 15 At the same time, NHS providers in a One CCG (Cumbria) is split across two footprints; b Office for National Statistics 2014 population estimates used; CCGs = clinical commissioning groups; STP = Sustainability and Transformation Plan England ended 2015/16 with a £2.45 billion deficit; the second successive year that the overall spending limit for the Department of delivery. Their impact is as yet unclear. They Health has been under threat. It eventually represent an ambitious attempt to redraw avoided breach by some creative accounting the public sector landscape, including and the use of underspends elsewhere. Two- healthcare, in the future. thirds (65%) of the 240 NHS providers, mostly acute trusts, reported a deficit. Delayed The future transfers to care are estimated to have cost Commissioning will continue to evolve. Most the sector £145 million, while £751 million notably, efforts focus on commissioning for were paid out in fines and readmission outcomes and not the process, more patient- penalties to commissioners. 16 and population-based commissioning and a From a purely financial point of view, need to focus on gainsharing rather than commissioning simply is not working in its cost-shifting. current form. At the time of writing, it is The direction of travel has been set by the reported that NHS England will overspend its previously mentioned Five Year Forward View , budget (including CCGs) in 2016/17. 17 which sets the scene for the period up to 2020. This highlights the need for a radical upgrade Devolution in prevention and public health, with a focus From 1 st April 2016, the Greater Manchester on national action on obesity, smoking, alcohol Combined Authority took on new powers and other major health risks. 5 under devolution arrangements, 18 which will There is to be a concerted effort to break lead to the appointment of a directly elected down barriers between family doctors and Mayor in 2017. The £22 billion of public funds hospitals, between physical and mental it now controls include a £6 billion health health, and between health and social care. and social care budget. The scope of the The future will see far more care delivered agreement includes the entire health and locally, with some services provided in social care system in Greater Manchester, specialist centres, and will be organised to including adult, primary and social care, support people with multiple health mental health, community services and conditions, not just single diseases. 5 public health. The agreement also provides a New models of care are proposed, with framework for strategies around governance multispecialty community providers, and regulation, resources and finances, integrated hospital and community providers, property estate, health education, workforce and primary and acute care systems mooted and information sharing, and systems being and now being brought into place. brought together. A great deal of focus has been placed on Further devolution arrangements, varying the future financial sustainability of the system in their type, have been announced. These and the cornerstone of this work has been the involve Cornwall, Liverpool and London. requirement for local health economies to These arrangements fundamentally produce multi-year Sustainability and impact on both commissioning and service Transformation Plans (STPs).

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In December 2015, the NHS Shared G deliver on some of the key national Planning Guidance 2016/17 –2020/21 19 priorities and strategies that have been laid outlined a new approach to help ensure that out – mental health, cancer, learning health and care services are built around the disabilities and others needs of local populations. To do this, every G make the STP process work. 22 health and care system in England will In his own words: ‘ So, in a nutshell: yes, it has produce a multi-year STP, showing how local been a tough year. Yes, it is going to be tough services will evolve and become sustainable sledding over the next three, four, five years.’ 22

over the next five years – ultimately References delivering the Five Year Forward View vision of 1. House of Commons Health Committee. Commissioning. Fourth Report of Session 2009–10, Volume I . 2010. www.publications. better health, better patient care and parliament.uk/pa/cm200910/cmselect/cmhealth/268/268i.pdf (last accessed 1 August 2016) improved NHS efficiency. 2. NHS England. Specialised services. www.england.nhs.uk/ commissioning/spec-services/ (last accessed 1 August 2016) To deliver plans that are based on the 3. NHS England. National Programmes of Care and Clinical Reference needs of local populations, local health and Group. www.england.nhs.uk/commissioning/spec-services/npc-crg/ (last accessed 1 August 2016) care systems came together in January 2016 4. NHS England. Next steps on Specialised Commissioning . 2014. www.england.nhs.uk/wp-content/uploads/2014/10/item7a-board- to form 44 STP ‘footprints’. The health and 1114.pdf (last accessed 1 August 2016) 5. NHS England. Five Year Forward View . 2014. care organisations within these geographic www.england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf footprints are working together to develop (last accessed 1 August 2016) 6. Department of Health. National Health Service, England. The STPs, which will help drive genuine and Primary Medical Services (Directed Enhanced Services) Directions 2016 . www.gov.uk/government/uploads/system/uploads/attachment_da sustainable transformation in patient ta/file/513892/Directed_Enhanced_Services_Directions_2016_acc.p df (last accessed 8 August 2016) experience and health outcomes of the 7. NHS England. Primary Care Co-Commissioning. longer term. 20 www.england.nhs.uk/commissioning/pc-co-comms/ (last accessed 1 August 2016) The footprints should be locally defined, 8. Department of Health. Public Health in Local Government . 2011. www.gov.uk/government/uploads/system/uploads/attachment_da based on natural communities, existing ta/file/216708/dh_131904.pdf (last accessed 1 August 2016) working relationships and patient flows. They 9. NHS South East Coast Strategic Clinical Networks. South East Coast Cancer Strategic Clinical Network. Who commissions what in cancer? should take account of the scale needed to 2014. www.secscn.nhs.uk/files/2914/0307/1568/South_East_Coast_ Cancer_Strategic_Clinical_Network_Commissioning_Responsibilitie deliver the services, transformation and s.pdf (last accessed 1 August 2016) 10. Pulse. Nicholson awards NHS England ‘five out of ten’ for first- public health programmes required, along year performance. with how they best fit with other footprints. www.pulsetoday.co.uk/news/commissioning-news/nicholson- awards-nhs-england-five-out-of-ten-for-first-year-performance/200 Table 2 shows how these STP footprints are 06211.fullarticle (last accessed 1 August 2016) 20,21 11. Vize R, in the Guardian. Simon Stevens calls for end to ‘cookie split across the NHS regions. cutter’ approach to NHS reforms. www.theguardian.com/ healthcare-network/2014/may/01/simon-stevens-cookie-cutter- First published 2016 STP footprints are not statutory bodies, nhs-reforms (last accessed 1 August 2016) This publication, along with but collective discussion forums, which aim 12. NHS England. Commissioning Support Units. www.england.nhs.uk/commissioning/comm-supp/csu/ (last the others in the series, is to bring together health and care leaders to accessed 1 August 2016) available online at 13. HSJ – Health Service Journal. Revealed: winners and losers of www.whatisseries.co.uk support the delivery of improved health and CCG support framework. www.hsj.co.uk/news/commissioning/ The data, opinions and revealed-winners-and-losers-of-ccg-support-framework/ care based on the needs of local populations. 5081784.article - .VPjHnvmsVyU (last accessed 8 August 2016) statements appearing in the As yet, they do not replace existing local 14. HealthInvestor UK. Private sector consortium wins article(s) herein are those of commissioning support services contract. 20 the contributor(s) concerned. bodies, or change local accountabilities. www.healthinvestor.co.uk/ShowArticle.aspx?ID=4523 Accordingly, the publisher, (last accessed 8 August 2016) and their respective Some see this as the beginning of the 15. NHS England. Consolidated 2015/16 Year-end Financial Report . employees, officers and end for CCGs and perhaps even 2016. www.england.nhs.uk/wp-content/uploads/2016/05/item7-26- agents, aaccept no liability 05-16.pdf (last accessed 1 August 2016) for the consequences of any commissioning itself. It certainly marks a 16. Public Finance. NHS deficit tripled in size to £2.45bn in 2015-16. www.publicfinance.co.uk/news/2016/05/nhs-deficit-tripled-size- such inaccurate or new era of central control in an attempt to ps245bn-2015-16 (last accessed 1 August 2016) misleading data, opinion or 17. HSJ – Health Service Journal. NHS England forecasting first ever statement. bring both commissioners and providers overspend. www.hsj.co.uk/topics/finance-and-efficiency/nhs- Published by Hayward together. During 2016, the STPs will be england-forecasting-first-ever-overspend/7009560.article (last accessed 1 August 2016) Medical Communications, a completed and have to demonstrate how 18. 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